Potential Cisatracurium-Induced Malignant Hyperthermia: A Case Report

Malignant hyperthermia is a pharmacogenetic disorder that manifests clinically as a hypermetabolic crisis when a patient with a mutation in the ryanodine or dihydropyridine receptor genes is exposed to neuromuscular blocking agents. Depolarizing neuromuscular agents are known to cause malignant hyperthermia, but cases caused by nondepolarizing agents are rarely reported. We present a case consistent with malignant hyperthermia after receipt of cisatracurium, a nondepolarizing anesthetic agent. A 57-year-old male patient presented with shortness of breath and increased edema of the lower extremities, found to be clinically volume overloaded. Respiratory status did not improve with diuresis and non-invasive ventilation. He developed severe acute respiratory distress syndrome necessitating endotracheal intubation and ventilation. The patient was beginning to clinically recover when he went into several instances of cardiopulmonary arrest with the eventual return of circulation. An intravenous infusion of cisatracurium was initiated to improve ventilation, and the patient's core temperature rose to 109 degrees F shortly thereafter. Dantrolene was given with an improvement in temperature just before the patient's family opted for comfort measures. Based on our analysis using the Naranjo score for adverse drug reactions, cisatracurium was the probable culprit for the development of malignant hyperthermia. The development of malignant hyperthermia in response to non-depolarizing neuromuscular blockers is a very rare phenomenon but should remain on the list of differential diagnoses in the setting of rapid rise in temperature so that dantrolene may be administered as quickly as possible.